Category Archives: Centers for Medicare and Medicaid Services (“CMS”)

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Enforcement of the Two-Midnight Rule Delayed Again

Last week President Obama signed into law a measure to extend Medicare physician pay rates for one year and to extend the enforcement delay of the “Two-Midnight” rule through March 2015.  Medicare Recovery Audit Contractors (RACs) are prohibited from auditing inpatient hospital claims for compliance with the rule from October 1, 2013, through March 31, … Continue Reading

New Approaches – and Increasing Oversight – for Medicaid Managed Long Term Services and Support

Approximately one-third of Medicaid spending, $136 billion, is on long-term services and supports (LTSS).  While the majority of Medicaid LTSS takes place in institutional settings, such as nursing facilities and mental health facilities, there is an ongoing emphasis on the role of non-institutional facilities. A growing number of states, from 8 in 2004 to 16 … Continue Reading

A Review of CMS’ Approach to $125 Million Recoupment of Payments to Providers for Services to Incarcerated / Unlawfully Present Beneficiaries

CMS seeks to recover from providers $125 million in alleged overpayments for services to beneficiaries who are belatedly identified as ineligible (incarcerated/unlawfully present). In this post, Sheppard Mullin examines the recovery process CMS has put in place, noting CMS procedural shortcomings and reviewing some substantive defenses available to providers facing such demands.… Continue Reading

CMS Announces Participants in Bundled Payments for Care Improvement Initiative

The Centers for Medicare & Medicaid Services (CMS) recently announced that over 500 organizations will begin participating in the Bundled Payments for Care Improvement initiative. The large number of participating organizations now exceeds the number of Medicare ACOs, and makes the Bundled Payments initiative the largest voluntary Medicare payment innovation program. Participating organizations are located … Continue Reading

CMS Announces Physician Payments Sunshine Act Final Rule

The Centers for Medicare and Medicaid Services (CMS) have finally announced the final rule for the Physician Payments Sunshine Act, which will require applicable manufacturers of drugs, devices, biological, or medical supplies covered by Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP) to report payments or transfers of value provided to physicians or teaching … Continue Reading

Senators Push CMS to Implement Physician Payments Sunshine Act

By Eugene Ngai In a roundtable discussion of the Senate Special Committee on Aging last week, Senators Chuck Grassley and Herb Kohl called on CMS to issue final regulations implementing the Physician Payment Sunshine Act, which was enacted as part of the Affordable Care Act. The Sunshine Act requires certain companies such as pharmaceutical and … Continue Reading

Observation Services at Risk Once More

By Karie Rego Just as you hospitals have their clinicians understanding that they need to specifically order observation services, the MACs and RACs have a new way to deny observation claims. At a recent speech, the Medical Director of the Medicare Administrative Contractor Cahaba (which processes claims for many of the for-profit systems out of … Continue Reading

CMS Releases Self-Referral Disclosure Protocol for Stark Violations

By Ken Yood and Lynsey Mitchel On September 23, 2010, the Centers for Medicare and Medicaid Services ("CMS") released its Voluntary Self-Referral Disclosure Protocol ("SRDP") that healthcare providers and suppliers can use to disclose violations of the physician self-referral statute or Stark Law (Section 1877 of the Social Security Act). The protocol potentially offers promising incentives for … Continue Reading